Audit and Implementation Guide: Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputations

Transcription

1 2nd Edition Audit and Implementation Guide: Clinical guidelines for the pre and post operative physiotherapy British Association of Chartered Physiotherapists in Amputee Rehabilitation NICE has accredited the process used by the British Association of Chartered Physiotherapists in Amputee Rehabilitation Accreditation is valid for 5 years from 10 January 2017 and is applicable to the guideline processes described in Clinical guidelines for the pre and post-operative physiotherapy.

2 About this document: This document summarises the audit tools developed to monitor the compliance of services and individual practitioners to clinical guidelines for the pre and post operative physiotherapy as described in the literature and expert opinion. Please refer to the guideline process document for full details of all methodology and processes undertaken in the development of these recommendations. Citing this document: Smith S, Pursey H, Jones A, Baker H, Springate G, Randell T, Moloney C, Hancock A, Newcombe L, Shaw C, Rose A, Slack H, Norman C. (2016). Clinical guidelines for the pre and post-operative physiotherapy. 2nd Edition. Available at About BACPAR: The British Association of Chartered Physiotherapists in Amputee Rehabilitation (BACPAR) is a professional network recognised by the Chartered Society of Physiotherapy (CSP). BACPAR aims to promote best practice in the field of amputee and prosthetic rehabilitation, through evidence and education, for the benefit of patients and the profession. Comments on these guidelines and the additional documents should be sent to: Sara Smith, BACPAR Guidelines Coordinator, Douglas Bader Rehabilitation Centre, Queen Mary s Hospital, Roehampton, London, SW15 5PN Introduction The first edition of this guideline was published in This second edition seeks to integrate new scientific evidence and current best practice into the original recommendations and create additional recommendations where new evidence has emerged. This audit and implementation guide has been developed to assist clinicians and stakeholders in implementing the recommendations into their clinical environment and clinical practice. The need to audit: It is recognised by validated guideline appraisal tools that a guideline should present key review criteria for monitoring and audit. The previously developed audit tool was reviewed as part of the updating process; comments were sought via the consensus panel and users of icsp website. Using the audit tools: The revised audit tool has been split into three parts, giving three distinct tools: Service evaluation Personal achievement of good practice points (GPPs) Patient notes audit form It is hoped that these standalone audit tools will decrease some of the time burden on the auditor as they can be completed at separate times and could be utilised as evidence of continued professional development (CPD). An action plan proforma has also been provided as Audit tool 4 for use where no workplace-specific forms are available. Application of the audit tools: Locally agreed standards need to be set regarding: The timings of audits/re-audits using these audit tools. The compliance targets. It is BACPAR s belief that it is reasonable to expect that any clinician providing pre and post operative physiotherapy management to adults with lower limb amputation should adhere to 100% of the GPP s presented in this document as a minimum for safe practice. These guidelines are not mandatory and BACPAR recognises that local resources, clinician enthusiasm and effort, support from higher management, as well as the rehabilitation environment in which the practitioner works, will influence the ability to implement recommendations into clinical practice. CPD activities: Examples of CPD activities and evidence can be found at Health Professions Council (2010) Continuing Professional Development & your registration. documents/ cpd and your registration.pdf

3 Audit Tool 1: Service Evaluation Date Audit data collected: Name of Auditor: Recommendation Yes No N/A Comments / Evidence Actions The role of the physiotherapist within the multidisciplinary team adheres to the recommendations of the guidelines. There is documented evidence of on-going formal and informal training and CPD in the pre and postoperative management and rehabilitation of adults with lower limb amputations and of reflective practice by the physiotherapist Written information is available to support routine verbal information Locally agreed, amputee-specific outcome measures are utilised, within agreed timeframes, by the physiotherapy team The physiotherapy team has established links with their local podiatry/chiropody services Physiotherapists can refer patients to a specialist multi-disciplinary team, including a diabetic specialist, podiatrist and foot care specialist as appropriate. Local protocols and competencies exist to cover specific treatment modalities and ensure that the physiotherapy team is working within appropriate scope of practice, or appropriate supervision is available. Planned Re-audit date:

4 Audit Tool 2: Achievement of Good Practice Points (GPPs) Date Audit data collected: Name of Auditor: Details of the GPP Yes No N/A Supporting evidence Actions Section 1 GPP 1: The MDT agrees its approach to rehabilitation. GPP 2: Roles and responsibilities are agreed within the MDT. (GPP) GPP 3: Patient and public involvement should underpin service delivery and development. GPP 4: Establish channels of communication between: The MDT Stakeholders Commissioners Professional networks GPP 5: Education, audit and research should be undertaken on a regular basis by the MDT. GPP 6: Documented pathways of care should be used. GPP 7: Contact details of MDT members should be readily available to the patient and carers. GPP 8: Access to other stakeholder agencies should be understood and agreed to facilitate discharge planning and transfer of care, e.g. Intermediate Care Teams, Social Services, etc. GPP 9: A summary of the patient s treatment and status at transfer or discharge should be documented in the patient s record, with details of future management plan, e.g. details of package of care, community therapy, prosthetic referral. Section 2 Section 3 GPP 1: There should be opportunities for CPD and lifelong learning. GPP 1: A locally agreed amputee-specific physiotherapy assessment tool should be used. Section 4 Section 5 GPP 2: Names and contact details of the MDT members involved in the patient s care should be recorded to facilitate communication. GPP 3: The principles of the Single Assessment Process (SAP) should be considered to improve MDT communication. GPP 1: Names and contact details of the MDT members involved in the patient s care should be given to patients and carers. GPP 2: Information leaflets/booklets should be developed locally for patients and carers to supplement information given verbally. GPP 3: Physiotherapists should be aware of the BACPAR guidance entitled Risks to the contra-lateral foot of unilateral lower limb amputees and Guidance for the multi-disciplinary team on the management of postoperative residuum oedema in lower limb amputees. GPP 1: The physiotherapist should be involved with the MDT decision to proceed with amputation and level selection. Where this is not possible, a procedure for prompt referral to physiotherapy following decision to amputate should be developed.

5 Details of the GPP Yes No N/A Supporting evidence Actions Section 6 GPP 1: Information leaflets/booklets should be developed locally for patients and carers to supplement information given verbally. GPP 2: Information on self-management/home exercise following discharge should be provided to the patient. GPP 3: Patients requiring ongoing outpatient treatment should have this arranged prior to discharge. GPP 4: A summary of the patient s treatment and status at transfer should be sent to the physiotherapist providing on-going treatment. GPP 5: Contact names, telephone numbers and addresses of relevant MDT members should be supplied to patients prior to discharge. GPP 6: Physiotherapists should be aware of the BACPAR guidance entitled Guidance for falls prevention in lower limb amputees and Guidance for the multi-disciplinary team on the management of post-operative residuum oedema in lower limb amputees. GPP 7: Physiotherapists should be aware of the wellestablished PIRPAG exercise program. GPP 8: Physiotherapists should consider the option of ascending and descending the stairs using a seated method. GPP 9: Physiotherapists should be aware of other relevant guidelines including AGILE and the OT guidelines. It is acknowledged that some patients will receive pre and post operative care in more than one service setting as part of an agreed pathway. In these circumstances the physiotherapist will only be expected to achieve the good practice points appropriate to their service.

6 Audit Tool 3: Audit of Patient Notes Date: Name of auditor There should be documentation found within the patient notes to support the recommendations. Where this information is found a tick ( ) should be inserted; where the information is absent a cross (X) should be inserted. Recommendation Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Action There is documented evidence of: A full physical examination and assessment of previous and present function. The patient s social situation, psychological status, goals and expectations. Relevant pathology including diabetes, previous arterial reconstruction, impaired cognition and skin condition. A problem list and treatment plan, including agreed goals, formulated in partnership with the patient. There is documented evidence of: Information provided to the patient about the expected stages and location of the rehabilitation programme suited to their individual circumstances. Information provided to the carers, with the patient s consent, about the expected stages and location of the rehabilitation programme suited to the patient s individual circumstances. The physiotherapist offering patients the opportunity to meet other adults with lower limb amputations, if appropriate. Where appropriate, and with the patient s consent, the physiotherapist offering carers the opportunity to meet other adults with lower limb amputations. The physiotherapist providing information about the prosthetic process if the patient was likely to be referred for a prosthesis. The physiotherapist offering to show demonstration limbs if the patient was likely to be referred for a prosthesis. There is evidence of written information provided to supplement verbal information. There is evidence of appropriate goal setting, including: Patients/carers have been made aware of any concurrent pathologies or previous mobility issues that may affect the outcomes of rehabilitation. Patients/carers have been made aware that the level of amputation may affect the level of function and mobility. Patients/carers have been made aware that they may experience lower levels of function than bipedal subjects. There is evidence of appropriate outcome measures used for rehabilitation goals. There is evidence that goal setting considers the impact of cognitive impairment. There is written evidence that: Vascular and diabetic patients and their carers have been made aware of the risks to their remaining foot and educated in how they can reduce them. The patient/carer has been taught how to monitor the condition of the remaining limb.

7 Recommendation Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Action There is written evidence that: Advice has been given to the patient/carer on the factors affecting wound healing. Advice has been given to the patient/carer on the use of compression socks. Instruction has been given to the patient/carer on methods to prevent and treat adhesions of scars. The physiotherapist is giving on-going advice about residual limb care, as appropriate. There is written evidence of: A pre operative physiotherapy assessment or appropriate documentation if not possible. Rehabilitation/discharge commenced preoperatively. If appropriate and possible the patient was instructed in wheelchair use pre-operatively. A structured exercise regime commenced at an appropriate time. Bed mobility and transfers taught preoperatively. Assessment for physiotherapy respiratory care, if indicated. Appropriate physiotherapy respiratory treatment given if indicated. Pain control optimisation prior to physiotherapy treatment pre-operatively. If appropriate, and with the patient s consent, carers were involved in pre-operative treatment and exercise programmes. There is written evidence that: Physiotherapy assessment and rehabilitation commenced on the first day post-operatively. Pain was considered and adequately controlled prior to every treatment. Respiratory care was given if appropriate. Assessments informed the MDT regarding interventions and discharge planning. There is evidence that the physiotherapist was involved in home visits where necessary. There is evidence that a compression sock was supplied for reducing limb volume, in an appropriate and timely manner. There is written evidence that: Bed mobility was taught on the first day postoperatively. Sitting balance was re-educated if needed. Standing balance was re-educated if needed. Safe transfers should be taught as early as possible. Mobility post-operatively was in a wheelchair unless specified reasons were documented to teach a patient to use crutches/zimmer frame/ rollator. There is evidence that the potential maximum post-operative mobility has been considered. There is evidence that EWAs have been considered as part of the rehabilitation programme for all lower limb amputation patients as both an assessment and treatment tool.

8 Recommendation Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Action There is evidence that: The patient, carers and the multi-disciplinary team have been made aware that the risk of falling is increased following lower limb amputation. Rehabilitation programmes included education on preventing falls. Patients and carers have been given instructions on how to get up from the floor in the event of the patient falling. Advice was given in the event that the patient is unable to rise from the floor. There is evidence that the patient was provided with a wheelchair and appropriate accessories to include residual limb support (as appropriate) footplates, anti-tips and appropriate pressure management devices, and was taught how to safely use the wheelchair, including all accessories. There is evidence of contracture management through: Education of appropriate positioning. Education of stretching exercises. Appropriate treatment plans where formed. There is evidence that following on from the initial assessment, an exercise program was provided to address the problems identified, was relevant to the patient s goals, and was reviewed and progressed as appropriate. There is evidence that: The patient was made aware they may experience phantom limb sensation or pain post-operatively. Information and treatment regarding phantom limb sensation and pain was given as appropriate. Techniques for the self-management of phantom sensation and/or pain was taught as appropriate. Appropriate information and treatment was given for residual limb pain.

9 Audit Tool 4: Audit Action Plan Name of audit: Date completed: Name of person completing audit action plan Analysis summary of audit findings: Signature Action plan Action required By whom Timescae for work

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